Senior Manager, Clinical UM Operations – Automation

🕒 Novembro 2

🗽 New York – Remoto

🗽 New York – Remote

💵 $105.100 - $160.480 / ano

⏰ Tempo Integral

🟠 Sênior

⚙️ Operações

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Healthfirst

SiteLinkedInTodas as Vagas

1001 - 5000 funcionários

Fundada em 1993

🛡️ Seguros

🏥 Saúde

⚕️ Seguro de Saúde

Insurance • Healthcare • Healthcare Insurance

A Healthfirst é uma provedora de seguros de saúde dedicada a ajudar os nova-iorquinos a acessar cobertura de saúde acessível para indivíduos e famílias. Com mais de 30 anos de experiência, a Healthfirst oferece uma variedade de planos, incluindo gerenciamento de cuidados do Medicaid, Medicare Advantage, cuidados de longo prazo e planos de saúde essenciais. A empresa foca em fornecer opções de saúde de qualidade, benefícios abrangentes e suporte para garantir que os membros possam manter sua saúde e bem-estar.

Descrição

• Provide strategic and operational leadership for clinical utilization management activities • Advance UM modernization and transformation through future-state workflows, processes, and operating practices • Collaborate with UM leadership, consultants, project management, technology, and vendor teams on transformation priorities • Identify clinical and operational requirements, risks, dependencies, and impacts to frontline teams • Support operational readiness and adoption of new technologies and workflows through stakeholder engagement, training, implementation, and stabilization • Identify opportunities to use AI, automation, and emerging technologies to improve UM operations • Provide oversight and management for prior authorization, concurrent review, and service requests • Lead, coach, and develop UM managers overseeing interdisciplinary clinical teams • Ensure compliance with CMS, New York State DOH, and other regulatory requirements • Establish, monitor, and report KPIs, productivity, and quality metrics • Partner with Clinical Operations, Quality, Compliance, and Provider Relations • Use data analytics and reporting tools to identify trends and optimize resource allocation • Lead audit readiness, performance improvement plans, and corrective actions • Serve as subject matter expert and escalation point for complex or high-impact cases • Support system implementations and technology enhancements • Ensure timely and accurate completion of service authorizations and reviews

🎯 Requisitos

• Bachelor’s degree in Nursing, Healthcare Administration, or a related field from an accredited institution or equivalent work experience • NYS RN • Demonstrated understanding of UM regulatory requirements, clinical review process, and managed care operations • Leadership experience in managing, coaching and developing multidisciplinary clinical teams • Strong analytical, organizational, and problem-solving skills • Written and verbal communication skills with the ability to influence and collaborate across functions • Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment • Experience delivering AI-enabled platforms, advanced analytics solutions or new software platforms within healthcare operations • Experience managing enterprise software implementations with vendors, systems integrators, and internal IT teams • Ability to translate clinical and operational requirements into business processes, workflows, and technology requirements • Experience using operational data, KPIs, and performance metrics to identify opportunities and drive improvement • Prior experience leading a team of people leaders • Experience using Milliman Care Guidelines (MCG) criteria and other state-specific authorization requirements • Ability to interpret and operationalize regulatory updates and guidance from DOH and CMS • Experience working and/or managing in a virtual environment • Understanding of Medicare, Medicaid and/or Managed Long-Term Care Plan (MLTCP) • Experience as a case manager for long-term care programs such as PACE, MAP or MLTC • Strong understanding of value-based care principles and their application to MLTC populations • Experience accessing and maintaining patient health information (PHI) electronically in a shared network • Strong computer skills, including word processing, spreadsheets, and databases

🏖️ Benefícios

• Medical, dental and vision coverage • Incentive and recognition programs • Life insurance • 401k contributions • Competitive compensation and benefits package

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